Service pathways

SERVICE PATHWAYS

CHF AND COPD

TRIAL

6 VISITS/6WEEKS

SELF MANAGEMENT

RN will educate the Client/Caregiver to understand symptom management and early intervention.

RN will teach and review the aspects for client self-management of CHF and submit reports detailing nursing interventions and the clients ability to self-manage upon discharge of CCAC services.

SELF-MANAGEMENT

RN will assess the client’s cognitive and emotional status that may influence the ability to self-manage.

RN will assess the client’s functional status and physical assessment to include blood pressure, heart rate, JVP elevation, pulmonary auscultation, abdominal girth measurement, and lower extremity assessment.

SELF-MANAGEMENT

RN will liaison with Primary Care Providers and Specialists to ensure the client’s treatment plan is optimized.

RN will report changes in functional status to the Primary Care Provider and consult with the Care Co-ordinator re: service needs.

CHF LEARNING OUTCOMESWEEKS 1 and 2

Understands CHF and the importance of self-care to prevent/reduce complications.

Recognizes the signs and symptoms of CHF worsening and who to contact. Client education tool “CHF status Zone Reference Tool”.

Understands and follows the medication regimen including: type of medication, dosage, administration schedule, mechanism of action, and importance of compliance.

WHAT IS CONGESTIVE HEART FAILURE?

CHF• Heart failure (HF), also known as congestive heart failure, is a common

condition that develops after the heart becomes damaged or weakened by diseases of the heart including heart attacks and other medical conditions. HF occurs when the pumping action of your heart is not strong enough to move blood around, especially during increased activity or under stress. In addition, the heart muscle may not relax properly to accommodate the flow of blood back from the lungs to the heart. These abnormalities in heart function can cause fluid to back up in your lungs and in other parts of your body such as your ankles. The congestion in your lungs and lack of oxygen may make you feel tired and short of breath. Sometimes the fluid in your lungs can accumulate to the point where it can cause a life-threatening condition called acute pulmonary edema, requiring emergency treatment.

• http://www.heartandstroke.com

TEACH-BACK TOOL

TEACH-BACK “WHAT IS CHF”

“Your heart is a pump. CHF occurs when the pumping action of your heart is not strong enough to move blood around, especially during increased activity or under stress. In addition, the heart muscle may not relax properly to allow the flow of blood back from the lungs to the heart.”

TEACH-BACK “WHAT IS CHF”

“The signs of heart failure are:• Shortness of breath,• Weight gain from fluid build up,• Swelling in the tummy, hands, feet, and

ankles,• Feeling more tired. No energy.

TEACH-BACK “WHAT IS CHF”

“I want to make sure I explained it clearly to you clearly. Could you explain it back to me in your own words?”

EVERYDAY

Weigh yourself in the morning, after going to the bathroom, and before breakfast. Write down the date and how much you weigh.

Take your medicines as ordered by your doctor. Check for swelling in your hands, legs, and feet. Eat foods with low salt (sodium). Don’t add salt at the

table. Avoid processed, packaged, and prepared foods. Balance activity with rest. Keep walking or join a cardiac rehab program.What Zone ARE YOU IN TODAY Green YELLOW RED

GREEN

NO increase in shortness of breath.NO weight gain. Your weight stays the same.NO new swelling of your ankles, legs, or feet.NO new chest pain.NO new feelings of fatigue, dizziness, or

confusion.Have you had your flu shot?

YELLOW

Call your doctor or nurse if you have any of these.o Weight gain of 2 lbs in 2 days.o Shortness of breath that is worth than usual.o Swelling is worse in your hands, feet, or ankles.o New tiredness that is not made better by rest.o Fever of 38 Celsius (100.4 Fahrenheit) or higher.o New or increased shortness of breath when lying down.o New dizziness or feeling light headed.o Wheezing that is worse than usual.

RED

Go to the Emergency Department or call 911 if you have any of these :

o New chest pain or chest pain that is worse than usual.

o Shortness of breath that is much worse than usual.

o Confusion. Not able to think clearly.o Severe dizziness or fainting.

CHF LEARNING OUTCOMESWEEKS 3 and 4

Understands the reason for fluid restriction and follows the prescribed daily limit.

Weighs self daily and keeps a daily log. Knows when to call Primary Care Provider (2 lbs. in 2 days).

Receives diet counseling and understands the reason for adhering to a low salt diet (<2000mg/day). Adheres to a low salt healthy heart diet and restricts alcohol consumption.

CHF LEARNING OUTCOMESWEEKS 5 and 6

Conserves energy to allow for ADLs by ensuring adequate rest and sleep.

Understands the importance of smoking cessation for improved health outcomes

Client/Caregiver successfully passes the Teach-Back by zone (Green/Yellow/Red). Provide with written materials to support learning.

EVERYDAY

Weigh yourself in the morning, after going to the bathroom, and before breakfast. Write down the date and how much you weigh.

Take your medicines as ordered by your doctor. Check for swelling in your hands, legs, and feet. Eat foods with low salt (sodium). Don’t add salt at the

table. Avoid processed, packaged, and prepared foods. Balance activity with rest. Keep walking or join a cardiac rehab program.What Zone ARE YOU IN TODAY Green YELLOW RED

GREEN

NO increase in shortness of breath.NO weight gain. Your weight stays the same.NO new swelling of your ankles, legs, or feet.NO new chest pain.NO new feelings of fatigue, dizziness, or

confusion.Have you had your flu shot?

YELLOW

Call your doctor or nurse if you have any of these.o Weight gain of 2 lbs in 2 days.o Shortness of breath that is worth than usual.o Swelling is worse in your hands, feet, or ankles.o New tiredness that is not made better by rest.o Fever of 38 Celsius (100.4 Fahrenheit) or higher.o New or increased shortness of breath when lying down.o New dizziness or feeling light headed.o Wheezing that is worse than usual.

RED

Go to the Emergency Department or call 911 if you have any of these :

o New chest pain or chest pain that is worse than usual.

o Shortness of breath that is much worse than usual.

o Confusion. Not able to think clearly.o Severe dizziness or fainting.

TEACH-BACK “YELLOW ZONE”

“I would like to talk about a few things that might come up. I just want to make sure that you know what you would do if any of this happens.”

YELLOW

Call your doctor or nurse if you have any of these.o Weight gain of 2 lbs in 2 days.o Shortness of breath that is worth than usual.o Swelling is worse in your hands, feet, or ankles.o New tiredness that is not made better by rest.o Fever of 38 Celsius (100.4 Fahrenheit) or higher.o New or increased shortness of breath when lying down.o New dizziness or feeling light headed.o Wheezing that is worse than usual.

TEACH-BACK “YELLOW ZONE”

• I want to make sure I did a good job explaining this to you because it can be very confusing. Can you tell me ....

• What symptoms should you immediately

report to your doctor? • What weight gain you should report to your

doctor